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Disease management program gives patient new lease on life

Date
2012-12-10

After 14 years with emphysema, Shirley Tisdale was worn out. By the end of 2011, she couldn’t even walk through her house without gasping for air. And, despite frequent doctor appointments, emergency room visits and hospitalizations, her condition was only getting worse.

Today, Shirley has a new lease on life. She is able to attend church and family gatherings, do light housework and even spend time at the beach. This summer she fulfilled a long-time dream of going horseback riding. How was such a turnaround possible? It all began with a phone call from Virginia Schellhaas, RN, BSN, a Disease Navigator with the Reid Physician Associates Disease Management Program.

The program helps patients manage their medical condition so they can avoid being hospitalized and enjoy a better quality of life. Eligible patients include those at high risk for hospitalizations. In 2011, Shirley had come to the emergency department five times and been admitted six times for problems including pneumonia and respiratory failure. She was suffering from additional health issues, such as diabetes and high blood pressure.

“Shirley’s family physician, Dr. Phillip Scott, asked me to contact her in December 2011 and get involved with managing her care,” Virginia says. “He was very concerned because Shirley’s condition was deteriorating. Nothing he prescribed was helping, and he wasn’t sure anything more could be done for her—we wondered if it was time to begin hospice care.”

Virginia began accompanying Shirley to her appointments in hopes of better understanding the situation. Very quickly, it became evident Shirley was telling Dr. Scott one thing but doing another. “Shirley was on a very complex home care regimen that included prescription medication, blood sugar checks and breathing treatments,” Virginia said. “She insisted she was following the regimen closely, but her appearance, test results and symptoms showed she really wasn’t.”

Shirley was reluctant to admit the problem. “I needed so many medications. Every time I’d see Dr. Scott or go to a specialist or be hospitalized, there would be a change in the dose or the prescription,” she says. “It was confusing, but I didn’t want to disappoint Dr. Scott and tell him I wasn’t keeping up.”

Virginia was sympathetic but determined to help Shirley get better. She presented two options: hire a home health care service or find a family member to get involved. Shirley quickly identified her niece, Christina Philpott, as a possibility.

Virginia called Christina and asked if she would be willing to become Shirley’s “health care advocate.” This would involve creating a system to help Shirley take her prescribed medications, going to Shirley’s doctor appointments, monitoring her condition and communicating any concerns to Virginia. Despite having a busy life of her own, Christina agreed immediately.

“I knew Shirley hadn’t been doing well, but I assumed it was because of her disease,” says Christina. “It wasn’t until I went to her house and saw a bunch of full pill containers that I realized what was going on. I took over the responsibility of ordering her meds and putting them into dispensers and working with my uncle Oby to make sure she was doing everything she was supposed to.”

As a result of Christina’s involvement and Shirley’s participation in the Disease Management Program, Shirley’s condition has improved dramatically. She has been able to reduce her medications, goes to Dr. Scott’s office less often and has been hospitalized only two times this year. Her last hospitalization was in February, for only two days. She also  feels and looks much better and says her quality of life has improved greatly, allowing her to do activities that once seemed impossible.

“Before I got into this program, I felt helpless and exhausted from being sick — I didn’t want to deal with it anymore,” Shirley says. “It never occurred to me to ask the hospital or Christine for this kind of help, but I’m so glad I did.”

Shirley is one of many patients benefitting from the Reid Physician Associates Disease Management Program. Staff members make sure doctor appointments are made and kept, call patients regularly to check in, inform primary care physicians and specialists about any changes to the patient’s care plan, and work closely with the patient’s other caregivers.

“Virginia is my back up. If I have a question about Shirley’s care, I call her,” says Christina, who lives just a few blocks from her aunt and uncle. “I couldn’t do what I do for Shirley without Virginia’s help.”

Virginia is quick to sing Christina’s praises, too. “Doctors and nurses are dependent on what patients tell them about their care. We don’t go into the home setting,” she says. “Christina has been able to address specific issues and keep Shirley accountable when it comes to taking her medication. She is a wonderful asset to Shirley.”

For more information on Reid’s Disease Management Program, please call: (765) 935-8585.

 

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